QUESTION--The patient is a 53 year old Hispanic male diagnosed with a 5.7 cm papillary thyroid cancer in 7/2014. He had invasion of the trachea mucosa and 4/6 level 6 lymph nodes positive. He was treated with 157 mci I-131 8/26/14.
He had recurrence in the larynx in 2015 and in 7/2015 had a laryngectomy removing a 2 cm tumor and he had a right neck dissection 3/32 lymph nodes positive. He was treated with 156 mci I-131 11/2015. Post treatment scan showed neck uptake.
He had a PET scan 11/7/16 which showed a hypermetabolic spot in the right paratracheal area and innumerable small lung nodules consistent with metastasis. On 12/27/16 he had 2.1 cm right paratracheal lymph node removed. In 2/17/17 he had 200 mci I-131. Post treatment scan showed no uptake.
In 6/2017 he showed me a 1 cm nodule in his left biceps. Fna showed metastatic papillary thyroid ca. PET scan done 8/2017 showed skull lesion in the left inferior orbital rim suv peak 6.5 suspicious for metastasis. New indeterminate t6 spine lesion suv peak 3.Stable tiny right trapezius lesion suv peak 2. His recent suppressed thyroglobulin is 89 and stimulated thyroglobulin 2/10/17 was 700.

Do you have a recommendation on how to proceed? Should the different lesions seen on pet scan be approached locally with removal if feasible or radiation therapy? Should we consider systemic therapy at this point? Any advice would be greatly appreciated. Sincerely, Robert Heymann.

RESPONSE--The first option in this case is system therapy with tyrosine kinase inhibitors. Local therapies may be considered for lesions at high risk of severe complications or if significantly symptomatic. Radioiodine is no longer an option. Sincerely, F. Pacini MD